Why COVID-19 is battering New York so hard

New York always has a claim at the top. It’s got the nation’s biggest city, tallest buildings, best pizza and the baseball team with the most World Series rings.

Now, the coronavirus pandemic is defining the Empire State as first in the country in a much grimmer way. With more than 170,000 confirmed cases of COVID-19 as of April 10, the state has by far the most cases in the United States, with more than a third of the national total.

Its size and global importance effectively guaranteed that the pandemic would hit New York City, but the downstate area as a whole has suffered much more than those factors alone would necessarily suggest. With more than 19 million residents, New York state is a little bit smaller than Florida, but has about 10 times more reported cases. California has about double New York’s population, but far fewer coronavirus deaths. Both Gov. Andrew Cuomo and New York City Mayor Bill de Blasio have said New York City faces a challenge unlike any other in the past century – a struggle they have likened to war and the Great Depression. As of April 10, New York’s death toll of 7,844 is more than the number of people who have died from COVID-19 in the next 10 most-affected states combined. “9/11 was supposed to be the darkest day in New York for a generation,” Cuomo told reporters on April 9. “We’ve lost over 7,000 lives to this crisis. That is so shocking and painful and breathtaking. I don’t even have the words for it.”

Why is New York getting hit so hard? Public health experts say a combination of factors have contributed to the virus’s outsized spread in New York, including a politically charged federal response, urban density, racial and economic disparities, and the city’s role as a hub of global commerce and transportation.

But New York fared much worse than other diverse, globally connected cities that were among the first to identify cases of COVID-19, such as San Francisco and Los Angeles. One difference between New York and its counterparts in California was the less aggressive early responses by Cuomo and de Blasio – especially in delaying the implementation of social distancing – compared to California Gov. Gavin Newsom and San Francisco Mayor London Breed. “All of this likely allowed the virus to arrive here sooner than in other parts of the country and spread more quickly,” Tom Frieden, a former head of the Centers for Disease Control and Prevention, told City & State, referring to the city’s density and global prominence – but also being slower to adapt. “Earlier action would likely have prevented the worst of this epidemic peak.”

Seoul is a huge, densely packed hub, but the entire country of South Korea only has 204 deaths – fewer than Staten Island alone.

Comparisons with other places that developed early cases support that analysis. Seoul is a huge, densely packed hub, but the entire country of South Korea only has 204 deaths – fewer than Staten Island alone. The first known cluster of cases in the United States occurred near Seattle, but Washington state has seen much slower growth in its cases. Face masks have been credited with limiting the spread of the virus in some places, and the South Korean government committed early to providing masks to all of its residents. Cuomo publicly questioned the effectiveness of wearing face masks, even as the CDC has shifted toward encouraging their use.

Viral infections are easily transmitted in dense environments such as apartment buildings and subway cars, a factor that has been widely cited by New York’s fans and detractors alike. But while New York City is the nation’s densest city and metro region, San Francisco is the second-densest city and it has fared much better. Meanwhile, the number of cases per capita has actually been higher in many of New York City’s relatively sprawling suburbs and the outer boroughs than it is in Manhattan.

A closer look at the nature of New York City’s population reveals that it is uniquely dense compared to other American regions. While the New York City region’s average density is not much higher than San Francisco’s or LA’s, the New York City area is three times more tightly packed when viewed through the prism of population-weighted density, which factors in metrics like New York’s high concentration of jobs in the urban core.

New York City is also a global economic, cultural and tourist hub that attracts people from abroad like few other places in the world. New York’s first confirmed case of the disease, for example, was a woman who had traveled to Iran, which saw an outbreak earlier than the U.S. “It is likely that there were multiple patient zeros at the same time but undetected,” said Melody Goodman, the associate dean for research at the New York University School of Global Public Health. While New York and its West Coast counterparts are similarly connected to Asia through direct flights, new research from the NYU and Mount Sinai medical schools shows that New York’s early exposure to the new coronavirus came mainly from Europe.

While density and global economic ties increase risk, superdense city-states such as Hong Kong and Singapore have controlled COVID-19 much more effectively than New York. They have had the advantage, however, of controlling their own fate, while New York is under the thumb of a president criticized as incompetent and detached from reality.

The federal response, or lack thereof, has hamstrung every state’s ability to respond, but it has been especially problematic for the hardest-hit places. The Trump administration withheld crucial medical supplies, key approvals on expanding testing and political support for states’ efforts. “The initial federal response was terrible,” said Matthew Lamb, an assistant professor of epidemiology at the Columbia University Medical Center. “The U.S. federal government had two months to set up surveillance through population testing or targeting points of entry and chose not to. Consequently, the infections introduced here could not be isolated and the virus has spread.”

Trump, density and size explain some of the reasons why the pandemic has hit New York City so disproportionately – but key decisions by Cuomo played a big role as well.

Trump, density and size explain some of the reasons why the pandemic has hit New York City so disproportionately – but key decisions by Cuomo played a big role as well. New York seemed to lag in limiting residents’ public contact. Washington Gov. Jay Inslee began restricting public gatherings in his state on March 11. While the initial outbreak was growing quickly in New York, Cuomo didn’t order the closure of public schools in New York City and its neighboring counties until March 15 – four days after Seattle did the same. Some urban areas of California imposed stay-at-home orders by March 17. New York’s order began five days later – with deadly consequences.

If such actions had been taken just four days earlier, the pandemic might have been reduced by as much as 80%, according to Frieden. “If New York had moved to shelter in place two days later, cases and deaths would have doubled,” said Frieden, who heads an initiative called Resolve to Save Lives that aims to combat epidemics. Cuomo waited until other states led the way, including ones that had relatively minor outbreaks. Republican Gov. Mike DeWine made Ohio the first state to close public schools on March 12. Michigan Gov. Gretchen Whitmer began mobilizing her state’s emergency response in February. 

Given New York’s particular risk factors, the state had no time to waste, said Nirav Shah, a senior scholar at the Clinical Excellence Research Center at Stanford University and the former commissioner of the New York state Health Department from 2011 to 2014. “If you have one person coming into a city with COVID, that’s different than five people. It’s an exponential disease,” he explained. “One versus five means you’re at very different starting points.”

“If New York had moved to shelter in place two days later, cases and deaths would have doubled.” – Tom Frieden, a former head of the Centers for Disease Control and Prevention

These disadvantages were foreseen, but often insufficiently prepared for, by past city and state officials. Both the city and the state had made plans in the past two decades to deal with such a threat. Yet, stockpiles of critical supplies like ventilators were eventually squandered. By the end of January, both de Blasio and Cuomo were on notice that the coronavirus was coming to the U.S. “The next pandemic is coming. We’re not prepared for it,” read the headline of a Jan. 30 op-ed in The Washington Post written by Frieden, the former CDC director. Yet, both leaders waited until early March to take dramatic actions against the virus. The Cuomo and de Blasio administrations did not respond to requests for comment.

Another X-factor that could help explain the prevalence of the coronavirus in New York City is economic inequality. The city and the state regularly rank highly on lists of the healthiest places in the country, but health outcomes, like money, aren’t evenly distributed in one of the most unequal cities and states. Underlying health conditions such as obesity, liver disease and asthma put people at a higher risk of severe illness or death from COVID-19, and those same conditions correlate with poverty and race. And while New York has some of the finest hospitals in the country, many of which are concentrated in Manhattan, it also has scores of poorly ranked medical centers that have been struggling to keep up with their patient loads in the outer boroughs.

Black and Latino New Yorkers – who make up about half of the city’s population but nearly two-thirds of the COVID-19 deaths – are twice as likely to die from the virus as their white and Asian American counterparts. The Bronx, which is the city’s poorest borough and has the highest percentage of people of color, also has the city’s highest rate of infection. “I’m not surprised at all by these statistics and facts,” said Maya Clark-Cutaia, an expert on risk morbidity and an assistant professor of nursing at the NYU Rory Meyers College of Nursing. “What I am disappointed in is finding that the resources haven’t reached these communities despite knowing that these disparities exist.”

The city and the state regularly rank highly on lists of the healthiest places in the country, but health outcomes, like money, aren’t evenly distributed in one of the most unequal cities and states.

De Blasio addressed the racial disparities of the disease’s effects at a press conference on April 8, noting that the city’s high population of immigrants could have also contributed to the disease’s spread. New Yorkers who speak little or no English may not be receiving critical public health guidance. And fear of the government in the Trump era has kept some immigrants from managing their health problems, both before and during this current crisis. Trump’s anti-immigration agenda, de Blasio said, has “driven them away from a lot of the places they would have turned for support and health care.”

Cuomo does deserve some credit for his approach – which was largely based on state plans developed years ago – to the pandemic. He took command in early March, mobilized state government and rallied the Legislature to give him emergency powers (with some controversy) to deal with the mounting crisis. And, unlike Trump, he takes responsibility. “If you’re going to be mad at anybody, be mad at me,” the governor said in mid-March. His much-praised daily press briefings have provided a detailed statistical overview of the state’s growing needs for medical supplies and personnel, and how the state government is doing everything in its power to buy or borrow to meet those needs. He even has managed to gradually extract more federal aid from Trump, while de Blasio and some liberal elected officials in other states have struggled to work with the hypersensitive president. While the governor has been a steady hand during the crisis, some of his counterparts in other states arguably deserve national recognition as much as he does.

Would the governor do anything differently in retrospect? “No, no, I think New York was early,” Cuomo told reporters on April 8. “I think the actions we took were more dramatic than most and were frankly criticized as premature.” In fact, public health experts and a growing chorus of elected officials in the city were calling for the shutdown of nonessential businesses in the days before Cuomo made that move.

Density, global connections and a disorganized federal response made a big difference in placing New York at the epicenter of the pandemic. But political decisions mattered too. That is a lesson that other city, county and state leaders might want to keep in mind because, while things are bad in New York now, the virus is expected to spread quickly in other states and cities soon.